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Promoting End-of-life Advanced Care
Planning using Health IT
Session # 239, February 14, 2019
Jonathan Austrian MD, Medical Director, Inpatient Clinical Informatics
Glenn Doty RN, Senior Director, Clinical Systems & Transformation
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Guidance Outside Health System
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“Two interventions have consistently been shown to
help patients live their final days in accordance with
their wishes: earlier conversations about their goals
and greater use of palliative care services…”
- New York Times (May 10, 2017)
Guidance Outside Health System
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Supportive Care Program
Awareness of Patient Preferences
Inpatient Supportive Care Protocols
Screening
Data/Analytics
Change Management
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Jonathan Austrian MD
Has no real or apparent conflicts of interest to report.
Glenn Doty RN
Has no real or apparent conflicts of interest to report.
Conflict of Interest
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Background
Case for Change
Interventions
Outcomes
Barriers
Agenda
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Discuss the rationale for investing in Health IT interventions for
goals of care
Diagram the clinical workflow from screening to intervention for
patients who will benefit from goals of care interventions
Design Clinical Decision Support Interventions to promote
screening for patients who could benefit from Goals of Care
Conversations
Identify barriers to adoption of goals of care health IT interventions
Evaluate the impact of goals of care health IT interventions on
important clinical care process and outcome measures
Learning Objectives
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Health system based in New York City with locations across
the five boroughs, Westchester, Putnam and Dutchess
Counties, New Jersey, Long Island and Florida
230 locations including 6 inpatient facilities
3,600+ physicians serving over 3 million patients a year
#3 best medical school for research and #15 best hospital in
the US
Among 9 percent of hospitals nationwide to earn a 5-star
rating for safety, quality, and patient experience from the
Centers for Medicare and Medicaid Services
Winner of the 2018 HIMSS Davies Award for demonstrating
outstanding achievement in utilizing health information
technology to substantially improve patient outcomes and
value
NYU Langone Health
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Why Did NYU Langone Focus on
Advance Care Planning (ACP)?
Centers for Medicare and Medicaid Services data
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Key Findings:
12% of discharges and 18.6% of the
average daily census were end-of-life (EOL)
patients
26% of PICC lines, 42% of PEG tubes, and
38% of Tracheostomies were placed on
EOL patients
EOL patients compared to entire population:
2.05x Readmission Rate
1.8x Infection Rate
+2.9 days greater ICU length of stay
Quality and Utilization Analysis
“I would not be
surprised if this
patient passed away
in the next 6
months”
Hospice
Expired
+
+
End of Life (EOL)
Cohort:
Compared one year of adult
inpatient activity for EOL cohort
against entire patient population
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Supportive Care Pillars
Awareness of Patient Preferences
Inpatient Supportive Care Protocols
Screening
Data/Analytics
Change Management
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Supportive Care Pillars
Change Management
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The Mission of NYU’s Supportive
Care Program
To improve the quality of life for our end of life patients
Better align our clinical practice with the patient’s stated
goals
Empower our providers to give stronger guidance to
patients and families on what is appropriate at the end
of life
To reduce non-value added inpatient utilization in
patients near the end of life
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Supportive Care Program Goals
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Goal Description
Quality
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Reduce
readmission rate for end-of-life (EOL) patients in the
last 6 months of life
AND reduce proportion of all readmissions
that are incurred by EOL patients
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Reduce
total number of hospital-acquired conditions (HACs)
in
the last 6 months of life for
EOL patients
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Reduce
ED Visits for Oncology patients in last 30 days of life
Cost
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Reduce
Total Patient Days
for EOL patients in the last 6 months
and 30 days of life
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Reduce overall inpatient
variable direct cost in last 6 months of
life for EOL
patients
EOL Cohort defined as adult patients that were discharged to hospice or expired
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Clinical Workflow
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Supportive Care Pillars
Awareness of Patient Preferences
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1
Advance Care Planning Navigator in
Epic:
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1
8
Health Care
Agents
Patient Capacity
ACP Activation
Note
ACP History
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1
9
Health Care Agents
Patient
Capacity
ACP Activation
Note
ACP History
Patient
Capacity
HCA
Patient
Header
Full capacity
None
Incapacitated
(HCA indicated)
Active
Incapacitated
(No
HCA
indicated)
Not on file
Needs Review
Pending
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2
0
Health Care AgentsPatient Capacity
ACP Activation
Note
ACP History
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2
1
eMOLST
Code Status History
Prior ACP Notes
Prior ACP Documents
Health Care AgentsPatient Capacity
ACP
NoteActivation
ACP History
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Supportive Care Pillars
Screening
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Based on their clinical expertise, our providers answered
the following question for admitted patients:
This is called the “Mandatory Surprise Question” or “MSQ”
How Did We Identify Patients That
Would Benefit?
Would you be surprised if this patient passed
away in the next 6 months?
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The Mandatory Surprise Question
(MSQ)
THE MSQ IS AN OPPORTUNITY FOR THE PROVIDER
TO:
1. Quickly identify patients that may be near the end of
life
2.
Pause to consider possible modifications to the course
of treatment
3.
Make key decisions about the patient’s care trajectory
that are in line with Supportive Care best practices
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MSQ
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Mortality Predictive Analytics
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Supportive Care Pillars
Inpatient Supportive Care Protocols
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Standards
All patients Screened with MSQ
All MSQ = No patients should have ACP Note
All Predictive Analytics patients should have ACP Note
All DNR patients should have eMolst
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Standard Documentation ACP note
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Decision Support to Support Protocols
Pop up alert
Provider Checklist
SideBar Dashboard
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Pop up Alert
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Provider Checklist
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Transparent Analytics
Data/Analytics
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Supportive Care Metric Dashboard
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3
ACP Note Completion
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68
57
92
250
470
428
623
449
68
208
263
268
380
531
600
808
630
0
200
400
600
800
1,000
1,200
1,400
1,600
Qtr 3, 2016 Qtr 4, 2016 Qtr 1, 2017 Qtr2, 2017 Qtr 3, 2017 Qtr 4, 2017 Qtr 1, 2018 Qtr 2, 2018 Qtr 3, 2018
ACP Note Completion September 2016 through August 2018 (N = 6197)
Ambulatory Visit Hospital Encounter
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3
eMOLST Completion
3
1
6
12
22
23
37
57
35
33
41
65 65
79
67
81
96
106
93
136
150
170
223
187
224
0
50
100
150
200
250
eMOLST Completion August 2016 through August 2018 (N = 2012)
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3
eMOLST Rate for DNR Patients
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“I would not be
surprised if this
patient passed away
in the next 6
months”
Hospice
Expired
+
+
EOL Cohort:
Compared one year of adult
inpatient activity for EOL cohort
against entire patient population
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MSQ RESPONSE RATE
ADVANCE CARE PLANNING NOTES
MOLST DOCUMENTATION
34%
92%
92%
EOL Cohort
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Results
Average Daily Census (-6%,-13%)
Readmission Rate (-3%, -5%)
# of Hospital Acquired Conditions in Cohort (-42%, -57%)
Total Inpatient Days (-6%, -12%)
IP Discharges to Hospice (3%, 21%)
Variable Direct Cost (-17%, -9%)
FY18 vs FY17 Average for Patients in EOL Cohort (Manhattan and
Brooklyn)
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Barriers
Integration of eMolst
Education/Comfort
Accountability
Priority Fatigue
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Further Research
$7.5 million NIH Grant
NYU Langone Health Ronald O. Perelman Department
of Emergency Medicine (PI: Corita Grudzen MD)
35 clinical sites from 18 health systems across US
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Acknowledgments
Leadership Team
Nader Mherabi CIO
Bob Press MD PhD
Kim Glassman RN PhD
MCIT Build Team
Vicky Javier RN
Dave Randhawa
Meg Ferrauiola
Lani Albania RN
Value Based Management
Nicole Adler MD
Frank Volpicelli MD
Steve Chatfield
Will Winfree
Advance Care Planning Program
Christine Wilkins PHD LCSW
Tom Sedgwick LCSW
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Jonathan Austrian MD Jonathan.Austrian@nyulangone.org
Glenn Doty RN Glenn.Doty@nyulangone.org
Questions